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The Ayurvedic Clinician: the mindful approach to enhancing your clinical skills

Lelisa Balderama
California College of Ayurveda

 

Introduction
The presence of the clinician and the trust built with the client is itself an essential aspect of the client’s healing process. “Indeed it may be that the physician’s (clinician’s) most potent therapeutic instrument is the self.”[13]. This paper discusses self-awareness, intuition and empathy—three important characteristics for the clinician to cultivate. The model, narrative medicine, emphasizes these three characteristics in fostering a therapeutic relationship with the patient. It also discusses the role of evidence-based medicine approach for the Ayurvedic Clinician.
The goal is to be a “mindful clinician”—one who is a detached observer to one’s physical and mental processes in their daily tasks. This cultivation of self reflection enables the clinician to clarify his values so that he “can act with compassion, technical competence, presence, and insight.” [5]
Self-Awareness
Goleman claims that emotional intelligence is the key to success. He cites Salovey who categorizes emotional intelligence into five domains:
1. Emotional knowledge: recognizing our true feeling as it happens.
2. Managing emotions: handling one’s feelings that builds on self awareness; the capacity to rise above distress
3. Motivating oneself: harnessing one’s emotions to move forward, to act on an idea or to accomplish a goal.
4. Empathy: the capacity to know other people’s needs and wants
5. Handling relationships: the ability to thrive in relationships.
He also cites John Mayer who states that emotions can color the way we feel and think and therefore can define the limits of one’s capacity to “use our innate mental abilities and so determining how to do in life.” [6]
Reflection and self-awareness help the physicians (clinicians) to examine what is important and meaningful to them and therefore are able to deal more effectively with the difficult demands of their profession and resolve problems. This capacity for critical self-reflection pervades in all areas of their practice: the ability to communicate their knowledge as well as elicit information from their patients, the ability to make evidence-based decisions and perform technical skills, and the ability to define their values and act on those values.[5] Caraka Samhita also addressed this level of mindfulness: “Knowledge of the science of medicine is likened to the light for the purpose of illumination; one’s own mental faculty to the eye (for the purpose of seeing things).” He further claimed that when intelligence is combined with clarity, the physician makes no errors during the course of his treatment of a patient.

The capacity to be aware depends upon the presence of mindfulness. It means paying attention without judgment but with purpose and intention. “Its power lies in its practice and applications”. While the concept is simple, it is not necessarily easy. The patterns of unawareness and automatic thinking will strongly resist one’s effort when disciplining the mind to be still and silent. It takes consistent effort to change these patterns but as the mind is emptied of the daily distractions, then “creativity, intelligence, imagination, clarity, determination, choice, and wisdom” will arise within you. This effort to simply be with the present moment is called a “meditation practice”. It is not a ‘doing’ but ‘being’. It is not about improving yourself but appreciating where you already are. It is realizing that what you do at this moment shapes what happens the next moment. [9] “The gentle letting go of the demands and attachments of your mind represents the highest level of true strength and character in a human being.” [8]
A mindful clinician diminishes the boundaries between technical, cognitive, emotional and spiritual aspects of the practice. It is not only knowing the correct course of action, but recognizing the obstacles that blind your decision-making process. An umindful clinician puts forth the energy in blaming himself or others rather than being receptive to the lessons his errors has presented while the mindful clinician recognizes the incompetence and will develop a means to improve his weaknesses so that he is mentally and technically better prepared for the next situation. [5]

Intuition
Earl Spencer speaking of his late sister, Diana, Princess of Wales, shared that her gift was intuition which he described as “the distinctive feel for what is important” ( Funeral Service Tribute, September 6, 1997, cited by Epstein [5] ). The Oxford Dictionary defined intuition as an “immediate apprehension by the mind without reasoning.” (cited by Epstein [5] ). It has been described as a combination of insight and instinct, and an understanding based on previous knowledge. Some aspects of intuition relates specifically to perception--the recognition of patterns and subtle distinctions. [5]
In the medical environment intuition is viewed not as an “esoteric talent” but is attained through knowledge and experience and that it is a carefully learned skill; it is an essential tool which enables the clinician to gain knowledge without direct evidence while engaging with the patient. [2] A research article interviewed 14 homeopaths in which 4 themes were presented to explore the nature of intuition and how it is used in a clinical setting:

Theme 1: How homeopaths recognize and describe intuition. Most described it as a ‘gut feeling’, inkling’, ‘a sense’ and ‘a picture’. There was an awareness of intuition in which the participants reported how aware or conscious they were when experiencing their intuition; the descriptions implied a keen ability to read their patient’s nonverbal behavior or to sense the underlying message than what the patient is sharing which was then integrated into their case information. The intuitive perception seems to arise from empathizing with the patient. Researcher noted that it appears that the intuitive practitioner receive and understand useful information automatically, a “gestalt intuition”—using information perceived to fill in gaps, missing pieces or subtle connections between pieces of information. Most practitioners felt that the extraction of relevant information occurred rapidly and that it was difficult to pinpoint what led to the intuitive judgment.
Theme 2: Beliefs about the origin of intuition. Most felt that it arose mainly from knowledge and clinical/personal experience. Others described their intuition as a natural ability. Overall intuition was perceived as an integration of knowledge and personal intuition.
Theme 3: Types of intuition. Two types of intuitions experienced by the parishioners were identified and what their specific roles were during consultations. Intuitive perceptions is intuition based on careful attention-- picking up cues from verbal and non-verbal behaviors which provided a deeper and more insightful understanding of their patients. Intuitive hypothesis generation is a deductive process in which the intuition manifests itself through a sudden idea, followed by a series of testing their intuitive hypothesis and consequently helping them in their decision making. This type of intuition suggests a lack of trust in their ‘hunches’.
Theme 4: The Selective Use of Intuition: Trusting Intuition. The participants would only use their intuition when they felt it was valid and reliable. It is applied in two aspects: use of intuition about patients and the therapeutic relationship and intuitions about the treatment/prescriptive part of the practice. The patient-based intuitions were trusted at all stages throughout the consultation process but intuitions for remedy ideas and prescribing decisions depended when the intuition happened. If it happened during the early stages of the consultation, most practioners would wait until they have a detailed and quantifiable information before relying on the intuitive remedy. [1]
The use of intuition as clinical skills involves many methods. Kaplan talked about the “importance of unsolicited symptoms meaning that the clinicians should value “symptoms spontaneously offered by the patient far more than those given in response to direct questions”. It means that a clinician must be comfortable with silence so that the patient is given a space to share spontaneously and from this an intuitive clinician is able to elicit the deeper story of the patient’s mental/emotional processes. Kaplan shared a story from his mentor, Dr. Denis Somper, a classical homeopathic physician.. A woman in acute pain was describing her pain which she began to do and eventually remained silent. As usual, he remained silent and waited for the next ‘unsolicited symptom’. The woman feeling uncomfortable thumped her fist on the desk and yelled at the Dr. Somper: “don’t’ just sit there, do something”. The patient has not shared it but she demonstrated her symptom: angry when in pain. Dr. Somper gave her Chamomilla and it worked. Part of intuition is knowing when to be silent. Another way to develop intuition is cultivating a heightened awareness to nonverbal cues, from the dress of the patient, the patient’s patterns or responses, posture, speech, changes of moods, gestures of despair, joy and other emotions, and use of space. Kaplan points out that these observations apply to both the waiting room and the consulting room. When he sees a patient reading or carrying a book in the waiting room, he will often initiate a short conversation about the book or related subject which may offer clues about possible remedies for the patient even before the official consultation. [3] An intuitive approach in the clinical practice both encapsulates the rational and emotional aspects of patient support; fostering it can improve the quality of consultation by facilitating connection with the patient to improve decision making and patient outcomes. [10]

Empathy
Empathy is a way of understanding an individual’s subjective experiences by sharing that experiencing while maintaining the stance of an observer. The physician resonates with the emotional and cognitive aspects of the experience drawing from his background knowledge and previous experiences (consciously/unconsciously). These empathic messages come through posture, facial expression, emotional expression (laughs, grunts, groans) and more explicitly through his use of language and how it is conveyed (Goleman: 90% or more of an emotional message is nonverbal [6] ). For example, a doctor was seeing a young mother for gastrointestinal symptoms and shared with him that her teenage son had been hurt and was in the hospital. She was elusive about the details but the doctor sensed her agitation and through various means conveyed the message; “it is scary when your children are ill” which eventually open the guarded patient and she broke down sobbing. She then related more details about her son’s incident; it was the first time that she had been able to cry about it. Acknowledging the patient’s feelings is empowering and makes patients feel seen and heard. The doctor related another story of a medical student he was observing. During the consultation, the patient who was previously reserved became animated when asked about the presence of a headache. “I don’t even know what a headache is. I never had a headache in my life.” For some reason, this was significant to the patient, but the student, missing it, let the moment pass. A different approach would have been to say, “You are a very lucky man!” This simple acknowledgement gives the patient a chance to elaborate on the details if he wished and it would have enhanced the physician/patient attachment by affirming the patient’s success. [7] Caraka Samhita gave a gentle reminder: “ When a physician who even if well versed in the knowledge of the disease and its treatment does not try to enter into the heart of the patient by virtue the light of his knowledge, he will not be able to treat the disease.” [3]
Often patients are unaware of are confused by their emotional state and identifying the emotion helps to diffuse it and can mobilize the patient to confront its true meaning. Starting gently like saying “you seem upset” rather than “you seem angry” is less confrontational. Naming the emotion can be a good starting point of discussion. A doctor related that a patient visited his office for check-ups once a month for 1 year with minor aches or complaints that seems elusive to a diagnosis. Once the doctor saw through the pattern, instead of reassuring him, he simply acknowledged the patient’s concern and that he would keep a close eye on him. At the end of the year, the patient informed the doctor that his brother died of cancer at his current age and was afraid that it would happen to him, too. [13]
Physicians who scored high on patient satisfaction also scored high on test on sensitivity to emotions. And physicians who were more empathic were seen more as being effective in alleviating their patient’s sense of concern about their illness. In general, it is more important for patients to have a physician who is compassionate than a physician who is technically competent in determining the patient’s commitment to the therapeutic relationship. Studies have shown that many patients go to the physician’s office with physical complaints with an underlying psychosocial order. When the physician’s empathy facilitates the patient’s to more freely express his/her emotions and alleviate the distress, it can liberate the physician from having to listen or evaluate other somatic complaints, which can lead to invasive and perhaps harmful investigative procedures. Another role for empathy is in the management of shame and humiliation during the consultation process. Patients are often in the position to reveal personal information that they may feel is demeaning. This is especially true in this era where there is a correlation of patient behavior (such as poor diet, cigarette smoking, dangerous sexual practices, etc) and certain diseases. The patient’s sense of shame about his weaknesses and inability to care for himself can cause him to suppress important information. The empathic physician behaves in a way that will allow him “to be invited within the patient’s protective barriers.” Empathy also helps the physician to be more understanding or tolerating towards patient behaviors that would otherwise seem alien or inappropriate. Dealing with a noncompliant patient is probably one of the most frustrating tasks for a practicing physician (or clinician); with this type of patient, the physician feels undermined in his efforts to be helpful. A wise physician would need to put himself on the side of the patient without being judgmental (instead of taking the punitive stance). When empathy is used the physician acknowledges that patient behave in ways that are rational to them based on their own sets of assumptions, and experiences; he is able to set aside his own preconceived notions so that he can be fully present with the patient. [13] Caraka Samhita emphasized the importance of non-judgment: “Persons can further be considered to be authoritative only when they are free from prejudices of all kinds and who can see things objectively and in an infallible manner.” While he noted that this kind of absolute authoritativeness can only be found in the gods, nevertheless, he noted that human beings have the capacity at some level. [3]
Goleman believes “Being able to manage emotions in someone else is the core of the art of handling relationship” [6]. Diagnosing and understanding the patient’s affective state is just one aspect of empathy. It is what the physician does with this understanding—“that is, what the physician gives back to the patient—that gives empathy its therapeutic efficacy.” [13]

Narrative Medicine
“Stories are medicine”. They have such power and yet it does not require a person to action or be but to simply listen. Stories set the “inner life to motion” and this is especially important when the person’s inner world is feeling frightened wedged or corned. [11]
The sick person creates a personal illness narrative as a way to organize and give meaning to the events of his life. Part of that ordering is the need to tell the story—it is an evolving dynamic tale yet often there is no listener to acknowledge it. (Kleinman cited by Zinn [13]). The empathic clinician facilitates the patient’s building of the illness narrative that will make sense and give value to the experience. Medicine practice with narrative competence, is called narrative medicine—“it is the ability to acknowledge, absorb, interpret, and act on the stories and plights of other”. Methods such as reflective writing and reading of literature are used so the physicians can reach and join their patients in illness as well as recognizing their own journey through medicine. People with medical problems need physicians (or clinicians) who can understand their diseases, treat their sickness, and accompany them through the illness. Along with their scientific knowledge, physicians need to the ability to listen to their patient’s story, reflect and honor the story so that their decisions and actions demonstrates what’s best for their patient. Charon believes that narrative competence enables the physician to practice medicine with “empathy, reflection, professionalism, and trustworthiness.” Narrative knowledge is what one uses to understand the significance and message of the stories through cognition, symbolism and affective means: Who tells it? Who hears it? Why and how is it told? Barbara Herrnstin Smith (cited by Charon [4] ) defines narrative discourse as “someone telling someone else that something happened.” This definition implies that it requires a teller and listener, a writer and a reader, and a conveyance of message. Like a narrative, medical practice requires an interaction with another and that an authentic connection can be transformative to all participants. [4]
As the physician listens to the patient’s narrative story, he enters into the world of the patient through drawing from his own memories, experiences, associations, imagination, and interpretations to identify the theme or the main thread of the story. By listening first, the physician is in a better position to answer the patient’s narrative questions: “what is wrong with me,” “why did this happen to me?” Often there are no clear answers but by being an empathic witness to the patient’s narrative story, the physician can proceed to his tasks such as diagnosing, interpreting findings, conveying information to the patient and engaging the patient in obtaining effective care. If the physician cannot perform these narrative tasks, the patient might not weave the whole story, might not ask the most revealing questions and might not feel heard. The result of the diagnostic process might be unfocused, the clinical relationship shallow and ineffective. [4]
Physicians have turned to studying literature to grow in their personal understanding of the illness. There are now literature seminars and reading groups in the medical setting—physicians are reading well-written stories about illnesses to deepen their skills as readers and listeners. They are realizing that reflective narrating “illuminates aspects of the patient’s story—and of their own—that may otherwise not happen without the narrative”. Narrative writing by students and physician has become a staple in many medical schools and hospitals to increased reflection, self-awareness, and learning to see the illness through the patient’s eyes. Physicians are writing about their patients’ stories, showing up in special columns in the journals and in books and essays and some are allowing their patients to read what they have written about them. Through the narrative processes of reflection and examination both physician and patient grow in understanding about the illness and how to manage it. [4]
Charon writes a narrative story about her patient Ms Lambert (not her real name) who is 33 year-old woman with Chariot-Marie-Tooth disease. Many of her family members (grandmother, mother, nieces) have the disabling disease as well. Ms. Lambert, despite being wheelchair bound, lives a dynamic life. She has a son, vivacious, smart and energetic; she observes that her son has developed weakness in his legs. As she shares with her doctor, she is engulfed in sadness for her son. The doctor feels her pain and grieves along with the patient. The doctor shares a section in the article she wrote in which she describes her patient’s pain, her patient’s story. Ms. Lambert, after reading her story realized more clearly the depth of her anguish. Her sisters’ dismissal of her concerns regarding her son had added to her suffering. She felt relieved that her physician seemed to understand her pain. She asked if she could show the article to her sisters and added, “Then maybe they can help me.” Such is the power of the narrative process. [4]

Evidence-Based Medicine
Evidence-based medicine integrates “individual clinical expertise and the best external evidence from systematic research. Clinical expertise means proficiency and judgment acquired through clinical experience and practice. Clinical evidence means clinically relevant research regarding accuracy and precision of diagnostic testing, the significance of prognostic markers, the efficacy and safety of rehabilitative treatments and preventive regimens. New research findings deemed as clinical evidence both invalidates previously accepted diagnostic tests and treatments and replaces them with more powerful, more accurate, more efficacious and safer.” It involves seeking the best external evidence with which to answer the clinical questions. However while external clinical evidence can inform, it is depended upon the individual’s clinical expertise to decides whether that particular data applies to the individual patient. And if so, how the clinician does integrate it into a clinical decision. Evidence-based decision models, while very powerful tools, are not always used by clinicians especially in complex situations. Some aspects of the patient, such as personality, do not fit in predefined categories. [12]
“Medicine is both science and narrative, both reason and intuition.” [10] Being a good physician doesn’t just appeal to the best evidence as relying on it can limit the clinician to further reasoning and to deeper exploration. A mindful approach is: “compassionate informed action in the world, to use a wide array of data, make correct decisions, understand the patient, and relieve suffering.” In the ancient text, Caraka Samhita, this integration of art and science was implied: “Pratyaksa or direct observation is that which is comprehensible by an individual through his own senses and mind. Anumana or inference is the indirect knowledge based on reasoning.” [3]

Conclusion

The Ayurvedic Clinican’s main role is to foster an optimal healing environment for the patient. Thus, the clinician must understand the dynamics of the mental, emotional and physical aspects of the client and how its imbalances can distort the true nature of the individual and deplete the resources within himself/herself to heal. The Ayurvedic Clinician must also draw out the narrative illness of the patient, listen to its meaning, and to be there when the story unfolds and reveals its courage and its fears. In short, the clinician must be fully present with the patient.
The following are some of the qualities that Caraka Samhita deemed a good “disciple” (medical student): tranquility, generosity, aversion to mean acts, perseverance, freedom from vanity, presence of intellect, power of reasoning and memory, inquisitiveness for truth, modesty and absence of ego, ability to understand the real meaning of things, good character, purity, conduct, love for study, enthusiasm and sympathetic disposition.” [3] These are the qualities that reflect self-awareness, empathy, and intuition which in turn cultivates the inner self. When the inner self is nurtured, healing occurs within and we begin to trust ourselves more. Jampolsky stated, “ In developing trust we unlock the power and wisdom that is within us”. [8] The Ayurvedic approach uses that same principle to bring healing to our patients. What we as clinicians strive for (to be whole in spirit) is what we wish for our patients and our community. That shared goal brings a unique dynamic between the Ayurvedic clinician and patient in the medical realm.


About the Student Research Papers

The papers published on our website have been written by students of the California College of Ayurveda as a part of their required work toward graduation. After reviewing each paper, Dr. Halpern selects those papers that he feels are appropriate to publish. The information in each paper should not be construed as the final word on any subject nor should it be assumed that errors do not exist.